<%@ include file="/common/taglibs.jsp"%>

<head>
    <title><fmt:message key="wellness.title"/></title>
    <meta name="heading" content="<fmt:message key='wellness.heading'/>"/>
</head>

<body id="signup"/>

<div class="separator"></div>

<s:form name="wellnessProfileForm" action="savePwpSuppWellness" method="post" validate="true">
    <li class="info">
        <fmt:message key="wellness.message"/>
    </li>

    <li>
        <div>
            <div class="left">
            <fmt:message key="q1.healthview"/>
            <s:checkbox key="pwpSupplemental.hlthviewamhealthy" name="pwpSupplemental.hlthviewamhealthy" fieldValue="1" cssClass="text large"/>
            <s:checkbox key="pwpSupplemental.hlthviewgetsickeasier" name="pwpSupplemental.hlthviewgetsickeasier" fieldValue="" cssClass="text large"/>
            <s:checkbox key="pwpSupplemental.hlthviewseriousproblem" name="pwpSupplemental.hlthviewseriousproblem" fieldValue="1" cssClass="text large"/>
            <s:checkbox key="pwpSupplemental.hlthviewexpectedhealth" name="pwpSupplemental.hlthviewexpectedhealth" fieldValue="1" cssClass="text large"/>
            </div>
            <div>
            </div>
        </div>
    </li>
<!--
	<li>
        <div>
            <div class="left">
                <s:textfield key="main.clientid" theme="xhtml" required="true" cssClass="text medium"/>
            </div>
            <div>
                <s:textfield key="main.groupnumber" theme="xhtml" cssClass="text medium"/>
            </div>
        </div>
    </li>
-->
    <div class="separator"></div>   
    
    <li class="buttonBar bottom">
        <s:submit key="button.save" cssClass="button"/>
        <s:submit key="button.cancel" name="cancel" cssClass="button"/>
    </li>
</s:form>

<script type="text/javascript">
    Form.focusFirstElement(document.forms["wellnessProfileForm"]);
</script>
